Provider Demographics
NPI:1144362146
Name:BRUCE D CAMPBELL MD, LLC
Entity type:Organization
Organization Name:BRUCE D CAMPBELL MD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:434-978-1691
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:FREE UNION
Mailing Address - State:VA
Mailing Address - Zip Code:22940-0220
Mailing Address - Country:US
Mailing Address - Phone:434-978-1691
Mailing Address - Fax:
Practice Address - Street 1:4303 FREE UNION ROAD
Practice Address - Street 2:
Practice Address - City:FREE UNION
Practice Address - State:VA
Practice Address - Zip Code:22940
Practice Address - Country:US
Practice Address - Phone:434-978-1691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005624738Medicaid